RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04044
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20041011	
DATE REMOVED FROM TDRL:  20090105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “fibromyalgia” rated at 10%.

CI CONTENTION:  The CI requests that all conditions be considered.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20040805/20081125	VARD -20060127	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Fibromyalgia…	5025	40%	10%	Fibromyalgia	5025	40%	40%	
Chronic Fatigue Syndrome	Not Unfitting	Included in Fibromyalgia Rating	
Irritable Bowel Syndrome			
Migrainous Headaches			
Depression			
COMBINED RATING:  40% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:
  
Fibromyalgia Syndrome.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 30 June 2004, the CI complained of chronic back pain involving the lumbar spine, the muscles of the back, the hands and the knees bilaterally.  In 2003 the CI had visits for anterior thigh pain- probably secondary to overexertion, bilateral hand pain with a negative workup for carpal tunnel syndrome, low back pain after mowing the lawn, and left knee pain consistent with patellofemoral pain syndrome.  In mid-2003 she again complained of low back pain and pain in the shoulders and neck after mowing the lawn, along with pain and swelling in the left knee.  X-rays of the lumbar, for low back pain that developed post-partum, were negative.  Low back pain recurred after mopping and cleaning up at her unit and after heavy physical exertion.  A physical therapy (PT) evaluation noted pain over the sacroiliac joints and left paraspinous area along L1-L3.  Narcotic medication was requested in the absence of improvement with previously prescribed nonsteroidal anti-inflammatory drugs (NSAIDs).  In October 2003 the CI complained of cramps in the hands; X-rays were negative.  Low back and knee pain recurred and rheumatologic evaluation revealed an ANA (antinuclear antibody- a test for connective tissue disease) of 1:160.  Workup was negative, but a follow-up ANA was positive at 1:320 with a nucleolar pattern and a positive anti-DNA antibody test.  Laboratory studies were felt to be consistent with possible lupus, although her complaints were inconsistent with that diagnosis and she did not improve with a course of prednisone (a steroid); however, Plaquenil (hydroxychloroquine, an immunosuppressant for lupus treatment) was prescribed.  An MRI in October 2003 of the lumbar spine was negative except for metallic artifacts posterior to L4 and L5, in the disc space on the left side at L3-4, and at inferior superior margin of S1, which were felt to be related to prior epidural anesthesia when a needle fractured.  Pain in the knees and low back recurred late in 2003 and again in January 2004.  Facet injections of a steroid in the L3-L4 area were given by an anesthesiologist and were subsequently followed by facet joint injections at L4-L5 and L5-S1.  Pain decreased, but it moved up to T12-L2.  PT and chiropractic treatments for the low back pain were carried out.  A review of her medications in March 2004 indicated she was on Celebrex (celecoxib, an NSAID, Plaquenil), Paxil (paroxetine, an antidepressant), Robaxin (methocarbamol, a muscle relaxer), and Neurontin (gabapentin for nerve pain).  A second rheumatologic evaluation indicated the CI had a history of diffuse polyarthralgias, polymyalgias, nonrestorative sleep, migraine headaches, depression and anxiety with an essentially negative rheumatology workup except for some fibromyalgia tender points including the posterior occipital (back of the head) region and knees.  He did not favor lupus or an inflammatory arthropathy requiring immunosuppressive medications and noted that 15 to 20% of normal healthy population had a positive low titer ANA.  The rheumatologist felt the CI’s symptoms were most consistent with fibromyalgia and that the use of Lortab (hydrocodone, a narcotic) and acetaminophen (a pain reliever) raised issues of tolerance.  The CI was felt to be a candidate for Wellbutrin (bupropion, antidepressant) or other equivalent medication for symptoms of anxiety/depression (see below).  The rheumatologist felt the CI did demonstrate 18 of the 18 ACR (American College of Rheumatology) tender points as well as other findings consistent with the diagnosis of fibromyalgia.  He also noted the CI’s symptoms did appear and were refractive to the typical medications used to treat fibromyalgia.  The NARSUM examiner noted the CI indicated she had moderate pain throughout the day, which was exacerbated by physical activity and was centered in the low back, arms and knees.  Marked pain disrupted her sleep and made recreational and social activities nearly impossible.  According to the CI, with exception of narcotic analgesics, she did not experience much pain control at all.  On examination there was tenderness to palpation over the L3 through S1 area, a full ROM of the upper and lower extremities, an unremarkable neurologic evaluation, and a scar above the suprapubic area secondary to a prior cesarean section.

A P3 permanent profile was issued on 23 March 2004 for chronic fatigue syndrome/fibromyalgia with limitations of all physical fitness testing and all functional military activities except wearing a protective mask and all chemical defensive equipment.  Maximum carrying of 25 pounds was an additional restriction.  The commander’s statement dated 30 March 2004 indicated the CI’s disability impacted the performance of her duties in her primary military occupational specialty (MOS), which required frequent lifting, lowering and carrying or pushing and pulling 100 pounds over hundreds of feet.  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 30 March 2004, approximately 6 months prior to separation, the CI reported body aching, trouble sleeping, constant pain and the diagnosis of fibromyalgia.  No physical findings were noted; however, the examiner listed depressive symptoms under the psychiatric clinical evaluation discussed below.

At the VA Compensation and Pension (C&P) examination dated 19 April 2004, performed 7 months before separation, the CI reported bilateral hand pain since March 2003 with cramping and swelling, as well as swelling and pain in the left knee and back.  On examination forward flexion was 80 degrees, rotation 10 degrees, and lateral bending 25 degrees.  The CI refused to perform extension motion; however, she demonstrated a full range of motion (ROM) with donning and doffing clothes.  There was non-tender straight leg raising (to determine nerve root irritation) to 90+ degrees with seated and supine leg raises.  Her hands and knees demonstrated full ROMs without clinical findings and muscle strength was 5/5 throughout.  Neurologic evaluation was unremarkable.  X-rays of the chest, left knee, bilateral hands, and lumbar spine were normal.  The examiner opined the CI did not have clear-cut signs or symptoms suggestive of a connective tissue disorder.  

At the TDRL removal examination dated 2 September 2008, the CI gave a history of having had some joint pain with muscle pain and swelling.  She was treated with Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever), and over time, the CI took Valium (diazepam, an antianxiety medication and muscle relaxer), Gabapentin, and Methadone (a narcotic), to which she became addicted and underwent detoxification.  However, post-separation, she did not receive medical care until February 2008.  She worked as a dialysis technician, but did not go into work about eight times within the year.  She was prescribed Lyrica (pregabalin for nerve pain) and naproxen (an NSAID), which did help, but not all the time.  She had symptoms of chest pain with occasional swelling of the chest, pain in the hands, knees, back and neck and sometimes developed lymphadenopathy (swollen lymph nodes).  She also was extremely intolerant to cold and occasionally had a hot flash.  She also felt lethargic and had a loss of appetite.  When asked the exact difference between her symptoms at the time of the examination and the last time she was examined, she indicated the change was mainly the chest pain and lethargy, which prevented her from walking, running, and doing other activities.  A cardiology workup was not performed.  The symptoms were the same with flare-ups almost every other day.  She did not have any psychiatric conditions and abdominal symptoms resolved.  The examiner was not able to comment on the etiology of the chest pain, but the lethargy was consistent with the original fibromyalgia claim.  She gave birth to a son in 2006.  On examination the chest was normal as was the heart.  The CI did not have muscle, joint, or chest pain at the time of the examination.  Muscle tone, mobility and strength were intact.  Laboratory studies were normal, although the iron was low normal.  Pulmonary testing in May 2008 revealed a post testing result with a forced vital capacity (FVC) of 62% predicted and forced expiratory volume at 1 second (FEV 1) of 58%.  The examiner’s diagnosis was fibromyalgia, although he opined it was “not noted on examination or indicated by labs/tests,” but it most probably was stable since she did not have treatment until February 2008 and a rheumatology referral was made in August 2008.  The examiner noted that the CI had full time employment, but she received a warning of a termination because she took too many sick days.  Remote VA notes indicated that while on TDRL the CI had used non-prescribed drugs/medication for which she was subsequently treated.
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 40% rating using code 5025 (fibrositis, primary fibromyalgia syndrome) for fibromyalgia syndrome with diffuse pain, sleep disturbance, headaches, depression, anxiety, and bowel symptoms for TDRL placement.  The VA assigned a 40% rating also using code 5025 for fibromyalgia.  The PEB assigned a 10% rating using code 5025 for fibromyalgia controlled with continuous medication (on Lyrica) for TDRL removal.  The Board first addressed whether there is a route to a higher rating at the time of TDRL placement; however, the CI received the maximum VASRD rating for fibromyalgia and IAW DoDI 6040.44 “a combined disability rating may not be a reduction of the disability rating previously assigned.”  The Board then sought a route to a higher rating for the TDRL removal.  While the CI had widespread musculoskeletal pain, her symptoms were not on the surface refractory to therapy.  However, she did not seek medical care until February 2008, although she was self-medicating her condition.  At the TDRL removal examination she did not have any of the characteristic tender muscle sites necessary to confirm the diagnosis and was felt to be stable.  By her history she had fatigability, albeit she worked as well as cared for her husband and children.  Based upon her history of limited medical follow-up, improvement when taking Lyrica, and lack of physical findings on examination, Board members felt that the CI did not have the level of disability at the time of TDRL removal as she did at the time of TDRL placement.  Nevertheless, she did have symptoms and a medication requirement to warrant a 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the fibromyalgia condition, coded 5025 for TDRL placement and the Board recommends a disability rating of 20% for the fibromyalgia condition, coded 5025 for TDRL removal.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that chronic fatigue syndrome, irritable bowel syndrome, migrainous headaches, and depression were not unfitting.  The irritable bowel syndrome, migrainous headaches, and depression were not profiled.  Although the chronic fatigue syndrome was, the conditions were not implicated in the commander’s statement and were not judged to fail retention standards.  

Chronic Fatigue Syndrome.  The CI complained of fatigue all the time in September 2003 and was diagnosed with chronic fatigue syndrome in March 2004 based on trouble sleeping and  awakening fatigued as well as symptomatic fatigue with a severity of 10/10 (10 being the worst pain).  The VA noted chronic fatigue syndrome was included in the evaluation of fibromyalgia.

Irritable Bowel Syndrome.  The CI reported constipation predominant irritable bowel syndrome without diarrhea.  High fat meals contributed to nausea and stomach pain.  It was determined that the condition was partially secondary to low fiber intake in diet and increased fiber was recommended.

Migrainous Headaches.  A note in February 2003 indicated the CI had migraines for 10 months with photophobia (light sensitivity) and phonophobia (sound sensitivity) that occurred once a month.  Treatment consisted of intramuscular Toradol (ketorolac) and Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene) at the onset of headaches.  In April 2004 the CI had migraine symptoms, which were treated with Demerol (meperidine, a synthetic opioid analgesic) and Phenergan (promethazine, an antihistamine for nausea). 

Depression.  A note dated 21 November 2003 indicated the CI was treated for postpartum depression, while a note in April 2004 indicated the CI might be a candidate for Wellbutrin (bupropion) or equivalent SSRIs (selective serotonin reuptake inhibitors) for symptoms of anxiety/depression.  The CI indicated she was “very depressed of my physical condition.”  A note dated 21 April 2004 indicated the CI demonstrated symptoms of depression with pain amplification syndrome.  At the VA examination in April 2004 she reported a twitching on the right side of her face from her eye to her neck, which she related to stress and depression since after the birth of her child; and, she also described tearfulness.  She stated she underwent counseling and was placed on Paxil (paroxetine, an antidepressant) and Ambien (zolpidem, for insomnia).  She also reported her husband had been out of work for over a year after he was involved in a motor vehicle accident, which aggravated her depression.  The VA used depression in its rating evaluation of fibromyalgia.
The aforementioned was reviewed and considered by the Board.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and therefore no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition, the Board unanimously recommends a no change to the disability rating assigned at the time of TDRL placement and a disability rating of 20%, coded 5025 IAW VASRD §4.71a upon removal from the TDRL.  In the matter of the contended chronic fatigue syndrome, irritable bowel syndrome, migrainous headaches, and depression conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		PERMANENT	
Fibromyalgia Syndrome	5025	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20160011798 (PD201404044)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA